‘Avoid too early, too many, too frequently’

President Yoweri Museveni recently pledged at the London Summit on Family Planning that government would provide $5m towards family planning every year for the next five years. Health Minister Dr Christine Ondoa told Shifa Mwesigye how this commitment would be realized.

Why was it necessary for the Uganda government to make these commitments on family planning? How does family planning benefit the country?

Uganda, home to 34 million people, is growing at a rate of 3.2% per annum and has a high young-age dependency ratio – more young people than people of working age. In the last two decades, largely because of the population growth, the income of the average person in Uganda has grown only half (at 3% to 4%) as fast as the economy (7% to 8%).

If these trends continue, the total population of Uganda will rise to over 50 million by 2025 and over 100 million by 2050 without significant decline in the dependency ratio. This scenario presents both an opportunity and a challenge for achieving sustainable economic and human development. If not managed properly, the high population growth and young-age dependency ratio will put Uganda’s ambition of attaining middle-income status out of reach.

Moving forward, efforts will be placed on creating an enabling policy environment for family planning, increasing financial investment in health, human resource development and management, increasing commodities and supplies and effective delivery to reduce stock-outs. These proposed investments in health and family planning will significantly reduce maternal mortality, child mortality, and young-age dependency rate and accelerate Uganda’s progress towards the Millennium Development Goals and middle-income country status.

How do you plan to follow up on these commitments and make them a reality?

Regarding funding, the progress is as follows: this year, under the recurrent budget, out of the government allocation of about Shs 8 billion towards procurement of reproductive health commodities, Shs 3.2 billion ($1.28 million) was used to procure contraceptives. It is anticipated that Shs 8 billion will continue to be allocated for the same purpose on an annual basis.

Using the funds from the World Bank loan, the ministry of Health will procure more contraceptive commodities, including equipment, worth about $4.2 million, annually. In addition, donor financing will also support procurement of contraceptives. The development partners that have committed to support government are DFID, UNFPA and USAID. NGOs also do some procurement on a smaller scale.

On accountability for resources, a sub-account for reproductive health has been incorporated in the ongoing National Health Accounts survey. Soon, under a project called the Open Health Initiative, funded through the East African Community, a system will be set up for improving accountability for funds allocated to various aspects of reproductive health, including family planning, in the five EAC member states.

In terms of public-private partnerships in regard to family planning, my ministry has done the following: A strategy for alternative distribution mechanisms for contraceptives has been developed in order to improve the distribution system for family planning supplies, especially in the private sector. Delivering family planning services by NGOs and CSOs is ongoing and being strengthened too.

Establishing youth-friendly services in the health facilities and setting up of youth centres has commenced in the districts. This will help to increase counselling of the youth so that unwanted pregnancies are avoided. The youth will, in addition, be encouraged to delay the age at which they conceive, and thereby ensure good-quality lives.

What do these commitments mean to the person or woman in the village who continues to have many children amidst poverty?

In addition to the explanation above, family planning provides an opportunity for the individual to plan the age at which they can start having children, the frequency and when to stop. This ascertains that a woman will not have unwanted or unplanned pregnancies and will be able to complete their education. The family is also provided with an opportunity to have the number of children that they can afford to look after.

The National Population Council Bill has taken long to be passed, how would it benefit family planning?

The National Population Council Bill 2011 is not under the Health sector. It is under the ministry of Finance, Planning and Economic Development. We shall liaise with them to fast-track it.

Talking of improving delivery of reproductive health supplies, how do you plan to do that especially from the district to health centre IIs where stock-outs are rampant?

The National Medical Stores (NMS) is currently implementing the last mile delivery and this has considerably reduced stock-outs of medicines, including reproductive health commodities.

What do you plan to do differently regarding your commitment one which talks about developing and implementing integrated family planning campaigns?

Ministry of Health will work in partnership with the health providers in the private sector through the public-private partnership. We shall intensify the raising of awareness by using the village health teams (VHTs) to sensitize the community and mobilize them to use services.

Services will be taken to communities, especially the hard-to-reach communities, by conducting family planning surgical camps. Ministry of Health will scale up integration of family planning provisions into other services such as sexually transmitted diseases, HIV/Aids services and postnatal care.

Uganda continuously falls behind. What would improve the family planning landscape and make maternal health better?

It should be noted that Uganda has made noteworthy progress in providing family planning choices to millions of women in the last five years. Close to 1.5 million women are using modern methods of family planning today in Uganda, in comparison to 0.75 million five years back. This achievement alone has averted 8,000 maternal and 100,000 child deaths in the last five years. It has saved over $300 million as a result of fewer women requiring pregnancy-related medical care.

Even with provision of contraceptives, the fertility rate is still high. Why are women and men not warming up to smaller manageable families?

You see, the decision to have children is by a couple and individuals. For us, we give them the information and the means to do it. The ultimate decision of how many children one wants depends entirely on them. That one we cannot influence.

What will you do to make them improve their attitude?

As a ministry, we look at the health hazards mainly. But also the economic impact of large families. Most women with very many children start having the children very early, when they are below the age of 18. Then they have the children too frequently, sometimes almost every year or every other year. And they have too many and too late. They begin early and even in the late 40s they are still producing.

That really impacts very negatively on the health of the women. We are saying, start a family when you are ready, most preferably after a woman is 20 years or above. By that time, she has a well-developed pelvis, well-developed reproductive system and she will not have many of these complications like the fistula.

Our other advice is that you space the children. Three years will be good so that it gives the woman time for her body to recover completely and also give time for the baby to grow so that by the time you conceive the next child, this other baby is big enough. And that also limits kwashiorkor, underweight children, and marasmus.

When you conceive too soon, this other baby still needs attention, needs to breastfeed, but you have another one. The one who is already born is disadvantaged and the one who is conceived may also suffer disadvantages. That is our message, do not start giving birth too early and do not produce frequently and too many. Have a number that you can easily manage.

President Museveni has for a long time said he did not believe in birth control. Do you ever argue about these things? Is his attitude changing?

When you listen to the President explaining why a large population is necessary, you see his point. One of the things he says is that the African continent is every big. You can put the whole of USA, India, Australia, and Western Europe to fit in Africa and you still have space. Yet our population, compared to all these countries put together, is very small.

But he accepts that the kind of population we need is a population that is productive. And we need to work on making our people produce. I agree with him. If we made the youth productive, our population would be advantageous to us. But for me I look at it from the health viewpoint. Yes, a big population for a country is economically good if the people are empowered.

But now I am toning it down to the woman. I want this woman to start producing at the age of 20 but also in between to have her body rest before she gets the next baby so that her health and her baby’s health are insured. If you listen to the President’s argument in London, he tends to agree with that also. He agrees there should be spacing so that the health of the woman and her child are insured. So, there is no controversy with that, between us and him.